Medical Scribe Training Syllabus

What is a Medical Scribe?

Medical scribes work at documenting medical provider dictation and activities, allowing providers to spend more time with patients. Medical scribes accurately document provider patient examination and related activities, allowing providers to spend more time with patients.

Medical Scribes are trained medical information managers, specializing in charting physician-patient encounters during medical examinations, working directly with the provider directly or remotely. The patient information is entered by the scribe into the electronic health record in real time, at the direction of the physician or independent practitioner.

What You Will Learn

  • Complete knowledge of medical terminology
  • Understanding the elements of the physical examination process and record the exam details;
  • Electronic Medical Rcords;

What Does the Course Include

Time to Complete: Course is 500 hours, 225 classroom and 275 practicum

MODULE 1 – Medical Terminology
Chapter 1. Language Origins, Etymoloy
Chapter 2. English Grammar 101
Chapter 3. Medical Words, Blueprints, Nuts and Bolts
Chapter 4. Dynamics of Medical Vocabulary & Word Structure
Chapter 5. Body Dynamics
Chapter 6. Medical Instruments and Equipment
Chapter 7. Medical Specialties and Specialists
Chapter 8. Diagnostic Medicine
Chapter 9. Abbreviations
Chapter 10. Anatomy and Physiology
Chapter 11. Pharmacology
Chapter 12. Just For Fun

MODULE 2 – Medical Records
Chapter 1 Medical Records
A. Electronic Medical Records
B. Electronic File Transfer
C. Confidentiality
D. Data Entry
Chapter 2 Medical Reports, Formats and Types
A. Medical Dictation
B. Report Types
C. Outpatient Reports
D. Correspondence
E. Inpatient Reports
F. Operative Report
G. Discharge Summaries
H. Consultations
I. Autopsies
J. Interpreting Medical Records & Dictation

Chapter 1 – Industry History and Codes
A. ICD Codes
B. CPT Codes
C. HCPCS Codes
D. Evolution of Coding
Chapter 2. The Coder
A. Private Practice
B. Hospital Services
C. Coder Responsibility
D. Ethical Standards
E. Understanding What is Coded
F. Documentation
G. Medical Necessity
Chapter 3. ICD-9 Coding
A. ICD-10 Coding
B. Using Reference Books
C. General Coding Guidelines
Chapter 4. CPT Coding
A. Types of Services
B. CPT Coding Book Guidelines
C. Modifiers
D. CPT Book Sections
E/ Symbols
F. Unlisted Procedures
G. Evaluation and Management
Chapter 5. Software
Chapter 6. Legal Issues
Applied Coding Practicum
A. ICD-9 and ICD-10 Coding
B. CPT Coding
C. Reports 2 through 63
D. Evaluation and Management Reports
E. Supply Codes, APC, PCS
F. Appendix